Intra-household decision-making and child health outcomes, evidence from Ghana by Sarah Akuoni (Doctoral Research Student, Department of Economics, University of Sussex, Brighton ) PhD Conference, University of Sussex, Brighton 5th December 2014 OUTLINE 1. Motivation 2. Literature 3. Data and descriptive statistics 4. Empirical strategy 5. Results 6. Key findings 7. Conclusions and Next steps 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 2 Motivation The literature suggests a positive association between women’s bargaining power (BP) and child welfare outcomes, including health and nutrition. (e.g. Lundberg, Pollak & Wales, 1997; Duflo, 2003; Doss 2006; Fafchamps, Kebede & Quisumbing, 2009). But most studies use indirect measures of BP -(economic) proxies, as BP is difficult to measure and context related;. e.g. -non wage income transfers (Lundberg et al, 1997) ; assets (Doss, 2006, Fafchamps, Kebede and Quisumbing, 2009) Also while studies provide useful insights on importance of woman’s relative BP little attention is given to balanced BP (except Basu, 2006) 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 3 Motivation Also, limited number of studies use direct measures of BP due to constraints on data availability but different outcomes of interest - (Freidberg and Webb, 2006: Dito, 2011; Lépine & Stobl, 2013) This study uses a range of decision-making variables as ‘direct measures’ of BP; and examines their association across quintiles. Focus on under 5 nutrition due to importance of early childhood nutrition (Straus and Thomas, 1998; Schultz 1999; Alderman et al 2006; Hoddinott et al, 2011) Data: Ghana DHS (2008) covers several domains of decisions and child anthropometric data 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 4 Literature Child welfare outcomes linked to intra-household ‘bargaining’. (McElroy & Horney, 1980; Manser & Brown, 1981; Browning & Chiappori, 1998) - - heterogeneous preferences importance of relative bargaining power (BP) - separate spheres in non cooperation (Lundberg and Pollak, 1993, Browning et al 2006) key Assumption: Parents internalise children’s preferences 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 5 Key Empirical Literature – Relative education: mother’s with relatively better education than spouse has a bigger impact on Daughter’s height (Thomas, 1994; Ghana ) – Non-wage income: increases through change in policy shifted spending patterns in favour of children (Lundberg et al, 1997; UK Duflo, 2003; South Africa) – Assets: Current asset ownership positively associated with child related expenditure in Ghana (Doss, 2006) • Also positive association with child nutrition in Ethiopia (Fafchamps et al, 2009) – BP of mother positively associated with nutrition outcomes in Senegal; relative ethnicity as IV. (Lépine & Stobl, 2013) 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 6 Child Nutrition in Ghana Malnutrition persists in southern Asia and Sub-Saharan Africa. 1 out of 4 children under 5 are stunted, (UNICEF/WHO/The World Bank, 2014) 33% of children under 5 mortality caused by malnutrition. (UNCF 2011). Ghana typifies the Sub-Saharan situation (ICF Macro, 2010): 28% stunting; 14% wasting and 9% underweight 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 7 Key Variables: Data Child anthropometric outcomes Decision-making Fifth round of Ghana Demographic Health Survey (DHS) 2008 - 11,778 households, nationally representative. - 4, 916 women aged 15-49 and men 15-59 from half of households – source of information on decision-making of spouses –Valid anthropometric measures for 2,379 children from 1,742 households (208 single, 1,726 monogamous, and 445 polygamous) 2,360 linked with non-missing mother’s characteristics. 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 10 Child Outcomes • Z-scores of 3 child anthropometric measures: Height-for-age (HFA), Weight-for-age (WFA), Weight-for-height (WFH) • Z-scores (Zi) based on WHO (2006) world reference population is: ππ = ππ − π ππ₯ (1) Where: Xi is the anthropometric measure for child i π and ππ₯ are the median and standard deviation respectively of the WHO world reference group for child is age. 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 14 Child Outcomes Variable Obs Mean Std. Dev. HFA 2379 -108 164 WFA 2379 -83 119 WFH 2379 -31 136 Stunted 2379 28 45 Severly Stunted 2379 10 29 underweight 2379 14 35 wasted 2379 9 29 Percentage : 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 15 Kernel Densities of Z-scores 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 16 Decision-making Two measures: 1. Decisions related to separate domains – i.e. daily purchases, large purchases and spending her income, spending his income, fertility, seeking healthcare for woman and visits to her family. Question : “Who has the final say on decisions about ………” Responses: 1. 2. 3. 4. Woman alone Both decide Husband alone Other person “Yes” = 1 “Yes” = 1 “Yes” = 1 “Yes” = 1 “No” = 0 “No” = 0 “No” = 0 “No” = 0 For each question, a binary variable Ri is defined. Such that : Ri = 1 if “yes” and 0, otherwise. 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 17 Decisions 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 18 Decision-making variables 2. Decision Indices (πΌπ ) For each decision, (Di) is constructed such that: Di = 1, if R1 or R2 =1; Di = 0, otherwise The decision index πΌπ = π π=0 π·π Where: n= number of decisions under consideration as below: • Household: Decisions related to spending parents’ incomes (mother’s , father’s), household purchases (daily, large purchases) and fertility • 2. Mother’s welfare: Decisions related to mother’s welfare ( visits to family, seeking healthcare) • 3. All decisions 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 19 Decision Indices Woman’s involvement in household decision-making Variable Obs Mean Std. Dev. Women’s involvement in decision-making (Percent) : Large purchases 2171 55 50 Daily purchases 2171 75 42 Use of spouse’s earnings 2171 40 49 Use of woman's earnings 2171 63 46 Fertility 2171 76 42 Her health 2171 64 48 Her Mobility 2171 80 40 Household 2171 3.18 1.91 All 2171 4.62 1.91 Decision index: Source: Author’s calculation from GHDHS5, 2008 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 20 Empirical strategy Informed by (UNICEF, 1990) framework and adaptation of Fafchamps, Kebede & Quisumbing, 2009) J K L M n j ο½1 k ο½1 l ο½1 m ο½1 n ο½1 Z i ο½ ο₯ ο’ j HC j ο« ο₯ ο’ k PCk ο« ο₯ ο’ l CCl ο« ο₯ ο’ m SCm ο« ο₯ ο’ n DM n ο« ο₯ i Where: – – – – – – Yij = Health outcome (HFA, WFA, WFH) of child i from hh j HCj = vector of household characteristics PCkj = vector of parental characteristics CCij = vector of child characteristics SCm = location specific controls DMj= Decision-making variables 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 21 Results: Intra-household Decision-making and Child Health S. Akuoni 22 Results BP Measure HFA WFA WFH All domain Index 2.77 5.66*** 5.95*** HH decision index 5.45** 8.74*** 8.15*** N 2360 2360 2360 R-Squared 0.16 0.13 0.1 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 23 Results BP Measure HFA WFA Decisions about Daily Purchases and Child Nutrition Woman Both 18.78** 1.83 Man 3.91 -11.09 N 2360 2360 R-Squared 0.16 0.12 Decisions about freedom of mobility and Child Nutrition Woman Both 26.92*** 13.76* Man 17.5 -4.43 N 2360 2360 R-Squared 0.16 0.12 WFH -10.4 -17.63* 2360 0.09 -1.58 -20.56** 2360 0.09 * p<0.10, ** p<0.05, *** p<0.01; Robust standard errors clustered at the district level 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 24 Results 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 25 Results 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 26 Results 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 27 Key findings • Better long term nutrition outcomes with joint parental decision making on daily purchases and the woman’s freedom of mobility • Worse child nutrition outcomes where men have the final say relative to the woman having the final say • For the malnourished children, a woman’s freedom of mobility seems to matter most 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 28 Conclusions • That we only find significant results for decisions on daily purchases, and freedom of mobility may suggest that child nutrition is not affected in the same way by all bargaining domains or dimensions • While a woman’s involvement in decision making is associated with better nourished children, it would appear children are better off in the long term in families where parents make joint decisions • The multidimensionality of BP needs to be considered in policies aimed at altering household welfare allocation. • 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 29 Thank you for your attention! Key variables: outcomes The study employs the following three measures of nutrition, z-scores of child anthropometric measures : ο Height-for-age (HFA) measures effects of long term malnutrition; • HFA <2 sd’s implies child is stunted, <3 sd’s implies severe stunting ο Weight-for-age (WFA) measures effects of short term malnutrition; • WFA<2 sd’s implies child is underweight , <3 sd’s implies severe stunting ο Weight-for-height (WFH) measures a combination of long and short term nutrition; • WFH <2 sd’s implies child is wasted) 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 31 Literature Analytical framework for modelling child health outcomes: insert hyperlink (UNICEF, 1990). Empirical studies, use child, parent, household and community factors: (examples: Haddad & Hoddinott 1994, Duflo 2003, Fafchamps, Kebede & Quisumbing, 2009) 1. 2. 3. 4. Child characteristics –current age, sex, birth weight, birth order. Some studies (e.g. Fotso, 2007) include antenatal care, place of delivery, immunisation status birth interval and duration of breast feeding, whether the child suffered illness/disease Parent characteristics: Primarily Mother’s age, education, measures of mother’s nutritional status , employment/occupation; father’s age, education, occupation Household characteristics: household wealth, nature of dwelling, access to water and sanitation, size and composition, sex of head Community: Geographical location (e.g. rural urban); cultural norms (ethnicity) accessibility of health facility among others 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 32 Next steps • Use a Heckman 2 step approach to first model survival then child nutrition • Pooling DHS4 and DHS5 to increase N • Exploring the polygamy story further 27/06/2016 Intra-household Decision-making and Child Health S. Akuoni 33